What about quality? An interview with Peggy O'Kane

The National Committee for Quality Assurance is among the leading organizations in measuring health-care quality and developing systems and interventions to improve it across the system. On Thursday, it will release its latest State of Health-Care Quality report. Today, I spoke with Peggy O'Kane, president of the NCQA, about the report, and what it means for health-care reform.

What did your study find?

The short version is the level of improvement appears to be leveling off. Where we've seen tremendous improvement over the past 10 years, in the past year it's slowed down. We don't think we're sending a strong enough signal about the need to improve quality.

You said we've had huge improvements in the last 10 years. How did we attain them?

Purchasers asking for it. Some large Fortune 500 companies have had bonuses for health plans achieving certain quality targets. Health plans are a convenient entity to hold accountable.

What did the improvements look like?

If you look from 1996 to 2006, the percentage of patients receiving beta blockers after a heart attack went from 62 percent to 98 percent. The rate of having all the right immunizations at the right age tripled over 10 years. People are now following best standards for asthma practice at more than 90 percent. That's really great. It's been a thrill. It's disappointing to see this leveling off.

Has quality had a sufficient role in the health-care reform debate?

We've been very encouraged with the level of attention it's gotten. The hard part is keeping it in there now that everyone is horse trading and trying to dumb down requirements.

It's always seemed to me that quality doesn't get enough attention as a concrete benefit that reform can deliver. If I'm insured, and I'm now less likely to die from an unnecessary infection, or a medical error, that's a benefit for me. But it's not often talked about that way. You don't see people viewing increased quality as a deliverable.

Yeah, although we have a ways to go until we have real clarity on what we really want people to get from health care. There's a very good understanding among policy people that a lot of what we're paying for is not delivering benefits, and may even be putting patients at risk. But non-policy people tend to think more treatment is better. This is part of why health plans have such a black eye with the public. They say no to things that should be said no to. I'm not trying to defend the health plans, but that's one of the sides to this story. In a country where there's national health care, the country plays that role.

What are the three things you most want to see in the bill?

More funding for performance measurement. We're always robbing Peter to pay Paul to get the money to do it. There's money in the bill to fund people like us to do this kind of thing. There's good language on the exchanges that requires performance reporting on health-care quality, feedback from members on their experience with the plans, and standards for patient protection. And then there's payment reform. We need to use public policy to drive greater integration of care. We need to make delivery-system quality the worry of the people who are in it, not just the regulators who come around to look at it.

Why isn't it their concern already?

We currently have a fee-for-service system where you do better by doing more. For example, generating unnecessary visits, or doing procedures that don't need to be done. Think about the new technology available to us. You can do video visits now. Why would you do that? At Kaiser, they have capitated payments, so it makes sense. If you are in most of the system, you would lose money on that. Most of us would love to have our doctor answer our e-mails. But they don't do it because they get paid more for a visit.

"If you look from 1996 to 2006, the percentage of patients receiving beta blockers after a heart attack went from 62 percent to 98 percent. The rate of having all the right immunizations at the right age tripled over 10 years. People are now following best standards for asthma practice at more than 90 percent. That's really great. It's been a thrill. It's disappointing to see this leveling off."

There's this thing called a logarithmic curve...it's the idea behing the law of diminishing returns. Maybe that's why the rate of improvement slows when you hit the 90% mark. Just a thought.

She's right about one thing. One of the best things about Kaiser is being able to email doctors and get a response. That fact that in most circumstances that is an impossibility suggests as a matter of common sense that doctors are far less interested in treating patients than in running up their bills. This perception leads to hostility to doctors and other providers.

We've been very encouraged with the level of attention it's gotten. The hard part is keeping it in there now that everyone is horse trading and trying to dumb down requirements."

Into the Washington spin-speak translator.... no.

Its actually worth noting that for all we lament about our employer-based system, large employers have been at the forefront of the quality movement. They've been critical contributors to the debate and have pushed ahead with standards when government/medical groups would have asked for more study. The Leapfrog Group, in particular, has been an employer-based coalition with some modest success on the quality front.

NCQA has been and remains the leader in promoting quality of care in the U.S. They have used carrots and sticks to move health plans and providers toward more accountability for health care quality, but what remains to be done is to get consumers and patients to demand quality from their providers and plans. Peggy O'Kane has done a magnificent job with NCQA, keeping it relevant and moving the needle on quality. Kudos for a wonderful interview. Wish it had been longer.

There is no way to continue capturing these quality savings without single payer or at least a strong public option.

The people who need to improve quality and affordability most--the solo and small group practices--are increasingly opting out of Medicare and Medicaid. Private fee-for-service insurers have not been effective at persuading their providers to meet evidence-based standards.

Admittedly, there are limitations to these metrics. The people who design them are not adequately insulated from certain industry players which always seem to score well. But it's a start.

If we have single payer and we drastically and very quickly curtail provider payments (even greater than the SRG model would do) then how many doctors do you think will remain in practice? How many people will want to be doctors in the future when you can make as much as a doctor as say an electrician, an engineer??? Sure many will do it because of the idea of "helping people" but many others won't and we already have a shortage of docs. That would make the shortage worse at a time when we're looking to add some 25-30 million people to the system.

Pay for performance always sounds appealing, but providers tend to find ways to game whatever payment system the public and private insurers come up with. Gaining agreement on what will be measured (and how) is not easy, either. Consider Newsweek's report on the performance of high-profile cancer centers and community oncologists on accurate diagnosis and evidence-based treatment of cancer -- not much transparency there right now, but what metrics would all parties agree to? And how long would it take to reach that agreement? Sure, single-payer would help, but a lot of heavy lifting would remain.